Health history & immunization forms

The State of Oregon and Oregon State University require the submission of a completed health history form and proof of specific vaccinations, or proof of immunity. Please download the form that applies to you below, complete it electronically and fax it to Student Health Services at 541-737-9665.

Student health history form (PDF)

International student health history form (PDF)

College of Veterinary Medicine health history form

Upon admission to OSU College of Veterinary Medicine, this form must be completed and submitted to receive medical clearance. This form is in addition to the general health history form you must complete before your first term at OSU, and is just one part of the required documentation for Veterinary Medicine students (Word doc).

College of Veterinary Medicine Health History Form (Word doc)

Medical record Release of Information form

You may receive a copy of your records, or you may have a copy forwarded to your personal healthcare provider, by completing the Consent/Authorization to Disclose Medical Records form. You may also use this form to request immunization records from a prior school or clinic to satisfy the OSU requirements.

Consent/Authorization to Disclose Medical Records form (PDF)

Assignment of Benefit and Release of Information for Insurance Billing

Complete this form to allow Student Health Services to bill your insurance and for SHS to receive any reimbursement payable for services and supplies that you receive at SHS. Students are responsible for all charges remaining after insurance reimbursement to SHS.

Assignment of Benefit and Release of Information for Insurance Billing (PDF)

Request for itemized billing statement

If you need a copy of your itemized billing statement, please complete this form and place it in any of the “Request for Itemized Billing” boxes conveniently located on the 2nd floor of the Student Health Center. Your billing statement will be mailed to you. This statement contains all the coding that is needed for your insurance company to process your claim. This bill will not reflect charges from the SHS Pharmacy (please request those statements directly from the Pharmacy).

Request for Itemized Billing Statement (PDF)
How to fill out the HCFA-1500 form you will receive (PDF)

Advance directive form

An advance directive is a set of instructions that explain the specific health care measures a person wants if he or she should have a terminal illness or injury and become incapable of indicating whether to continue curative and life-sustaining treatment, or to remove life support systems.

Advance Directive Form (PDF)